Inspection on 13/10/09 for Bempton Old Rectory

This inspection was carried out on 13th October 2009.

CQC found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bempton Old Rectory 15/10/08

Bempton Old Rectory 28/09/06

Bempton Old Rectory 20/01/06

Bempton Old Rectory 18/10/05

Bempton Old Rectory 08/03/05

Bempton Old Rectory 27/10/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Bempton Old Rectory Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF Lead Inspector Janet Lamb Key Unannounced Inspection 13/10/09 09:00 DS0000019648.V378090.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bempton Old Rectory Address Vicarage Lane Bempton Bridlington East Riding Of Yorks YO15 1HF 01262 850072 01262 850072 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Dorothy Hunter Manager post vacant Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17) of places Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th October 2008 Brief Description of the Service: Bempton Old Rectory is situated within the small village of Bempton, near the coastal resort of Bridlington. The village has a number of local amenities including pub and village shops, as well as limited public transport to Bridlington. The premises, a grade two listed building, is set in its own grounds and has been extended and refurbished to provide people with a homely and comfortable environment. The home has lounges and dining rooms which are large enough to accommodate everyone who lives there. The home is registered to care for a maximum of 17 older people who may or may not have a dementia type illness. Some people’s private accommodation is on the first floor and a stair lift is provided. One room on the first floor requires the person to be able to manage a small set of stairs in order to reach it. The current weekly fees are £385.00 per person, and extras include hairdressing, toiletries and newspapers at cost. Information about the services provided is made available in the home’s Statement of Purpose, Service Users Guide and through published inspection reports obtained from the home. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0-star. This means the people who use this service experience poor quality outcomes. The Key Inspection of Bempton Old Rectory has taken place over a period of time. It involved electronically sending an ‘annual quality assurance assessment’ (AQAA) document to the home in June 2009 requesting information on how the home meets standards, about people, the health care professionals that attend them, and the staff working in the home. It also asked for numerical data held in the home. We received the AQAA in August 2009, but there was very little detail to show how the home meets standards. As part of the information gathering survey questionnaires were sent out, ten surveys were sent to people in the home, six to the staff and three to health care professionals. Information received from other sources over the last year and in notifications received from the home gave us an idea of what it must be like living in the home, as no surveys had been returned to us by the time we made a visit there. Then on the 13th October 2009 Janet Lamb, Regulation Inspector, carried out a site visit, to check out all of the information the Commission had received since the last key inspection and to ask people living there what it is really like. A second visit was made on the 23rd October 2009 to complete the site visit and to give feedback. Two people living in the home, the registered provider, two staff and two visitors were interviewed or spoken with and some interaction between people and between people and staff was observed. The communal parts of the home were inspected, and a small number of bedrooms were viewed during conversation with people. Care plans and all other documents relating to people, risk assessment documents and some records, etc. were seen and staff files and training records were also seen. All personal and private documents were only seen with the permission of the people they belong to. Safety maintenance certificates and records were also viewed. Requirements and recommendation made at the last key inspection were checked for compliance and action. As part of the last key inspection in October 2008 the home was asked to provide the Commission with an action plan to show how these requirements and recommendations were to be addressed, but no action plan has been received. This report is a summary of all the information viewed and obtained. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 6 been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Staff actually understand the needs of people living in the home, they provide people with attentive care and support to lead satisfactory lives of their choosing, and they generally meet people’s needs for personal and health care. Unfortunately none of this is backed up by the documentation held in the home. People’s privacy and dignity is actually well respected and people are treated with respect and compassion. Staff always explain to people what they need to do and why, and seek their cooperation. The home provides people with some activities and pastimes, though these could be better, it encourages and supports good contact with family and friends, offers opportunity for people to make choices and decisions of their own, and provides very satisfactory food. People enjoy a very clean, comfortable and safe environment to live in, which means Bempton Old Rectory is a homely place to live. There are some very caring and conscientious staff working there who know how to treat and care for people. What has improved since the last inspection? What they could do better: Prospective people moving into the home must be given a full and detailed assessment of their needs, information must be fully recorded and people must receive in writing confirmation their needs can or cannot be met by the home, so they know their needs will be met once they have moved in. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.2 Page 7 Copies of the placing local authority community care assessment document, where completed, and copies of the home’s own assessment of needs document must be held in case files, so people know their assessed needs informs the care plan staff are to follow to care for and support them. People’s care plans should be person-centred and must contain the relevant areas of assessed care needs for individuals and show what action or intervention is required to meet those needs. Care plans must be reviewed as required or at least annually and in consultation with people, family and social service officers if appropriate, so people know their needs are being well met. People’s care documents and records should be held together in the case file, so people and staff know when and how their needs are assessed, their care needs are to be met, and their care plans are reviewed. People’s risk assessments must be carried out using a risk assessment tool to evidence how risks are deduced and show that they are specific and relevant, so people know their needs will be met with as much reduced risk as possible. People’s individual health care needs must be fully recorded in their care plan and there must be evidence available to show how these needs are being met, so people are confident their changing needs are met. People’s medication brought into the home should be checked and receipted in the appropriate place on the MAR sheet or on some other record, and any returned medicines should be recorded and signed for upon collection, so people are confident they are receiving their medication safely. All staff administering medications must be properly trained to do so and be competence checked on a regular basis. All of this should be recorded as evidence, so people are confident they are receiving their medication safely. People must be consulted about activities and pastimes to determine their individual wishes and expectations, and they must be assisted to fulfil these, so they lead fulfilling lifestyles of their choosing. People’s complaints should be recorded in more detail in respect of any investigation, action taken and the outcome for the complainant, so people know their complaints are taken seriously and are resolved effectively. All staff must receive regular training in safeguarding adults, and have their competence checked for understanding. All of this should be recorded as evidence. It must be done so staff understand the current guidelines about who to report to, and what action to take, should they suspect abuse, or have an allegation made to them. All of this is so people are protected from harm. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 8 Refurbishment work on the bathrooms should be completed in a timely manner, so people know they have suitable bathing facilities to use. All staff recruitment and selection procedures must be followed and schedule 2 must be adhered to in respect of only employing people after making and receiving thorough checks with the Criminal Records Bureau (CRB). Two written references must be obtained for all staff. All of this is so people are confident they are cared for and supported by safe staff. All staff must receive mandatory training or be competence assessed on a regular basis in such as fire safety, moving and handling, medication administration, emergency first aid, health and safety etc. and all training must be recorded, so people are confident they are being cared for and supported by competent staff. The provider should appoint a manager to run the home, and s/he must submit an application to the Commission to become the registered manager, so people know the home is being run and managed by a person fit to do so. The quality assurance system should be developed to include surveying people more thoroughly and in a positive way and surveying relatives and staff. It should produce a published report of the collective results of surveys to show what the home does well and what the registered provider intends to do where suggestions about improvements are made, so people are confident their views underpin the development of the service. There must be a three yearly check on the hot water storage tank to test it for the risk of legionella bacteria and a certificate must be obtained as evidence, so people are confident they are protected from the risk of infection. All staff must undertake regular fire safety training drills to meet the requirements of the Humberside Fire & Rescue Service, these must be properly recorded and staff must sign to say they have taken part in the drills as evidence, so people are confident they are protected from the risk of harm from fire. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 9 order line – 0870 240 7535. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not have their individual and diverse needs completely assessed before they are admitted to the home, and so they are not confident their needs are fully met. People do not receive ‘intermediate care’ and so standard 6 is not applicable. EVIDENCE: Discussion with people in the home, the registered provider, two relatives and two staff, and viewing of case files, documents and records shows there are shortfalls in the way people’s needs are assessed. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 12 The provider carries out a pre-admission visit to people in their homes or in hospital and completes a ‘pre-admission form,’ which asks for information about the person in respect of their medication, the aids they use for mobility, their appetite, what assistance they need with personal care etc. Only one form was produced as evidence of the assessment of people’s needs and it did not contain a date, details were very brief, such as ‘walks with a stick, normal diet, see chart for medication taken’ and it did not give a full picture of the person’s physical, mental, social, cultural, religious, family contact etc. needs. It did not give a full picture of the person’s needs as the provider verbally mentioned further information that she was aware of, about the person, that was not included on the form. Copies of the placing local authority ‘community care assessment’ were not produced, though a large number of people living in the home privately pay for their accommodation and may not have had such assessments completed. This is one important reason why people should be thoroughly assessed in line with the areas listed in standard 3.3 before a care plan is produced, and because people must have all of their needs assessed in order to understand what assistance and support they will require once admitted to the home. We were shown a new assessment of needs document in blank format, which did have the potential to show more information and in more detail, but were told it has not yet been used. It asks for information on mobility, diet, continence, dressing, washing, eye sight, hearing, foot care, hairdressing, oral care, medication, medical history, current medical condition, mental capacity and social needs, and is more suitable to assess people’s needs in accordance with the areas listed in standard 3.3. This form has greater potential to record a person’s needs more thoroughly if completed with detailed information about the person being assessed. The problem lies with the quality of evidence being collected and recorded about people showing an interest in living in the home, as discussion with two of them that did choose to live there and two relatives, shows people are quite satisfied with the assistance and support they actually receive. Both people spoken with could remember having their needs assessed before they came to live at Bempton Old Rectory, but neither person had copies of these assessments in their case files. Unless there is evidence of a process it is not accepted that the process has been carried out. Standard 6 is not applicable. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, personal and social care needs are not robustly or thoroughly documented in a care plan, so they are not confident their needs are fully met. Medication administration does not follow a robust audit trail and so people may not be confident they are receiving their medication safely. EVIDENCE: Discussion with people in the home, the provider, two relatives and two staff viewing of case files, records and documentation and observation of some practices and relationships shows there are shortfalls in the way people have their health, personal and social care needs met and documented. There are individual care plans in place that the provider says are produced from the information gathered about people during their pre-admission Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 14 interview with them and their family at home, and from information gathered once they have decided to live in the home. Two care plans seen take the format of name, date of birth, GP etc. followed by a brief medical history and then the stated ‘aim’ and ‘task’ to be carried out to ensure each area of need is met. One care plan stated the details of the person’s allergies, their medication, personal self care, mobility, mental, dietary, communication, social and night care needs, with an ‘aim’ and a ‘task’ for each one of these. Some areas of need were grouped together, such as mental health, medical history and medication. These would be better dealt with if they were separate areas of need within the care plan. Because the two care plans seen do not have accompanying assessment of needs documents it is difficult to say whether or not the appropriate areas of need are represented thoroughly in them and whether or not omissions are justified. The care plans seen had been added to since the last key inspection to meet a ‘requirement’ of that report, to ensure information about people’s current health, social and psychological needs and any relating risks is included in the care plan. At a random visit to the home in March 2009 it was noted that care plans had begun to be reviewed, and at this key inspection it is noted that there is now a brief medical history with current health issues recorded at the beginning of the care plan. There are no clear details that show how and when care plans are reviewed in relation to a formal review with family and social services if appropriate, but there is evidence of care needs being considered on a monthly basis. Each month there is a brief summary of the person’s welfare and all documents completed that month are fastened together with the MAR sheet, GP visits record, diary notes and weight charts etc. for archiving. It is also noted that there is mention of risks in relation to current health and wellbeing. These risks are not deduced from having completed a risk assessment tool though, but are an opinion reached by the provider during the pre-admission interview or from observation on admission of the person to the home. Risk assessments need to be carried out using a risk assessment format and tool. Although in the last 12 months the provider has undertaken training with East Riding of Yorkshire Council in respect of ‘person centred care planning’ the care plans produced are not specifically person centred. People and relatives spoken with say they feel their care needs are well met in the home. One person says she does as much as she can for herself in respect of personal care, makes her own bed and mostly prefers her own company, but does need someone to cook and clean for her now, does need someone to handle her medication as it is so confusing these days, and does rely on family Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 15 to look after her finances. She says the staff are very helpful, caring and friendly and that everything is done for her. She is aware of her care plan being in place. Another person says staff are kind and most helpful, they meet her needs, on the whole she is happy and she feels safe. She is not aware of her care plan. One person’s relative explains there are many complex needs to meet for them and that the provider and staff are very understanding, flexible in the care they give and when, and that they seek to ensure the person’s optimum comfort and reduced stress. There is a very clear medication administration policy and procedure in the home that staff follow, but not in entirety. There is a medication policy file containing the policy and procedure and a copy of the Commission’s ‘advice on administering medication.’ There is a monitored dosage system supplied by Boots Chemist and there are medication administration record (MAR) sheets to record when drugs are administered. MAR sheets also have a picture of the person they refer to and there is a list of specimen signatures to identify the staff administering the drugs and making the entry. Medicines are stored in a locked cupboard in a locked room on the upper floor of the home. Medicines requiring cold storage are now kept in a designated lockable medication fridge and controlled drugs are kept in a double locked facility, which now meets the ‘requirement’ made at the last key inspection to ensure pharmacy advice is sought and implemented about cold storage medicines and controlled drug storage. Where the medication audit trail has shortfalls is with the receipting into the home of medicines on the MAR sheets and the obtaining of a signature on the list of returned drugs for those returned to the pharmacy. There is also a need to make sure one person’s controlled drug that she self medicates every three days is recorded and signed as handed over in the controlled drug register each time it is given to her. Staff have over the years completed various distance learning medication administration courses with such as York University, but some have not been trained or competence assessed for over three years. There is a medication administration course planned for some staff with Boots Chemist. This must be completed and staff must be competence checked regularly, and all of this must be recorded. There is no question that people in the home are treated with respect and that their privacy is totally upheld. People say they are treated kindly, they are listened to, they only receive personal care in private, they are addressed how they wish to be, receive their mail unopened, and staff knock on their door Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 16 before entering. Relatives also say they are highly satisfied with the care and support people receive. All information in case files refers to making sure people are asked about their wishes and choices, are told what care is about to be given to them or that they are about to be lifted etc. and that they are encouraged to make their own decisions on everything. We are told staff are instructed in staff meetings, supervision and on a daily basis to always inform people, seek their views and give them choices and encourage decision making. However, care and health care plans are not clear enough in their content or documented well enough to inform the staff what care people need, though the care people do receive is better than what is written in care plans. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have satisfactory opportunities to experience the lifestyle they expect and prefer, though it could be better. People enjoy good contact with family, friends and the local community, exercise choice and control over their lives and enjoy wholesome and appealing food. EVIDENCE: Discussion with people, the provider, two relatives and staff and viewing of case files, records and documents and observation of interaction between people and people and staff shows people tend to live their lives according to their choices. There are daily diary notes compiled on each person in the home, held in their case files and these records are collated on a monthly basis with a monthly summary about care plan needs also produced. Within diaries is information on where people may go, what they do and when etc. especially in relation to Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 18 social activities and entertainment. People tend to be less able than they used to be, but they talk about going on outings, going shopping, playing dominoes, watching television, reading books and magazines and receiving entertainers. There is still room for improvement in the daily life and social activities that people get up to. Some improvements were recorded at the random inspection visit in March 2009, as some indoor games had been held. People spoken with at this key inspection say they sometimes pass the time taking a ride out in the home’s bus, sit in the garden when the weather is good, or chat in the lounge. One person says they get out very rarely and always takes up the chance to go out when offered. She says there could be more in-house entertainment to choose from as well. Family and friends are able to visit any time, and the home tries to make them welcome. Clearly there is capacity for a balanced improvement in providing entertainment and occupation to people living at Bempton Old Rectory. A ‘recommendation’ made at the last key inspection to seek people’s views about activities provided has only been partly met since the provider says she asks staff to consult people, but the process is not formalised because there are no records of this. One night staff, also working a couple of days a week, now has responsibility to set up different pastimes and activities for people, though there are no plans or records of activities to view. Wherever possible people are encouraged to handle their own finances and almost all of them have finances handled by a relative or a solicitor. The home does not consider handling money for anyone, except to receive their accommodation charges on a weekly basis. There is no money held in safe keeping for anyone. Toiletries may be purchased for people on a daily basis from money they may carry on their person, but in these instances staff must return any change with a receipt for the actual amount available, directly to the person. There are no records of this. Therefore no financial records could be viewed or tested for effectiveness. People say they are satisfied with being able to keep small amounts of money on their person and for their relatives to keep control of their overall finances. Those people spoken with say they have been able to bring to their rooms pieces of their own furniture and possessions where there is space to take them. One person pointed out the wardrobe, an easy chair, a chest of drawers and a bookcase as being her own, while another explained the standard lamp, chest, bedside cabinet, occasional table and bedding were all hers. Staff say they are very mindful of acknowledging people’s possessions and their room as being their home. Meal times are generally set but can be flexible if people wish to go out or rise late etc. Most people take breakfast between 7 and 8am in their room before they wash and dress for the day. Many join together in the lounge/dining rooms at mid-day for lunch and at 5pm for tea, but there are still a number of people who always take meals in their room as they choose. Menus are Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 19 compiled according to a roster and consider the seasons for vegetables. People say they do not usually contribute to menu choices as they are not routinely asked, and that there is no set alternative, but if a meal is not liked or wanted then alternatives are offered and provided. One person eats a vegetarian diet and says the alternative is all too often eggs. She says on the whole the provider sees to it she gets well fed. People say they receive plenty of food, they never leave any and usually only know what is on offer when they ask staff during morning coffee time. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident they are able to complain and have their views listened to and acted upon. They are not entirely confident they are protected from the risk of harm or abuse because of lack of staff training in safeguarding issues and because of poor recruitment practices. EVIDENCE: Discussion with people in the home, the provider two relatives and two staff and viewing of some records and documents show there are appropriate systems in place for handling complaints and referring allegations to safeguarding teams, but there is a shortfall in the training of staff in safeguarding procedures. There is a simple complaint procedure that is in the ‘statement of purpose’ and posted on the home’s notice board. There is a record of complaints held though it was not viewed and we are told in the AQAA and verbally that none have been made in the last 12 months. Therefore the effectiveness of the system could not be tested. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 21 People say they know how to complain as they would always talk to the provider or one of the staff, but they have not had need to complain as everything is done for them. One person says she supposes she would make a complaint to her key worker. Relatives say they are well aware of the complaint procedure and would not hesitate to talk to the provider. They feel she is very approachable and usually resolves issues quickly. Staff in interview say they are well aware of the procedure for trying to resolve small issues when they are highlighted and to pass on more serious complaints to the provider as soon as possible. A ‘recommendation’ made at the last random visit to the home in March 2009 to keep a record of all complaints made and to include details of investigations and any action taken could not be checked because no complaint have been processed. Therefore it remains as a ‘recommendation’ on this report. There is a safeguarding adults’ procedure in place, held in a safeguarding file compiled by the provider, and the home has a copy of the Hull & East Riding Safeguarding Adults Board procedures and guidance. There is also a whistle blowing policy. There is a record held of referrals though it was not viewed and again we are told in the AQAA and verbally that none have been made in the last 12 months. The effectiveness of the system could not be tested. One regulation 37 notification made to the Commission in May, regarding a person’s behaviour, ought to have been referred to the safeguarding team for their consideration. Health care professionals were involved in the person’s care, however. People say they feel very safe at Bempton Old Rectory, that the staff are very kind and that they would speak up if they felt an injustice was being done to them or anyone else. One person says she would ask staff why they were being nasty to her if ever anyone was. Relatives also express confidence that people are well cared for, safe and well protected. Staff in interview demonstrate they understand their responsibility to protect people and know about the whistle blowing policy in place. They know how to pass on information to the provider or social services should they suspect or know about abuse being committed. Staff say they either don’t remember doing safeguarding training, it was a while ago, or they have actually had experience in making a referral in another service. There is no clear evidence that staff have completed a safeguarding adults training course in the last three years. A ‘recommendation’ made at the last key inspection and at the last random inspection to provide all staff with safeguarding training, has still not been met. The provider tells us she has completed the manager’s safeguarding training in March/April 2009 and that she is going to cascade all training down to the staff and has discussed safeguarding with them, but there is no evidence of this having been done in Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 22 either a formal training session or staff supervision. This is now a ‘requirement’ of this report. People are not entirely confident they are protected because of lack of staff training in safeguarding issues and because of poor recruitment practices as discussed in the section on ‘staffing.’ Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 23 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a safe, clean and comfortable environment to live in. EVIDENCE: Discussion with people in the home, the provider, two relatives and two staff and viewing of some of the communal areas of the home and some private areas with permission, shows the service continues to provide good homely accommodation. The home is situated in the quiet village of Bempton. The house is warm and comfortable and provides a variety of communal areas for people to choose from. It is well decorated and free from unpleasant smells. Some of the Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 24 communal areas look out onto the gardens, which are well maintained. People say they enjoy the gardens in the warmer months. The first floor is reached by a stair lift. There is one room on the first floor, which can only be reached by a small final flight of stairs. The provider says people’s assessment considers this before they move in. People have their own single room accommodation throughout the old building and the newer extension. All rooms have en-suite toilet and meet requirements of standards on space and furnishings. The provider tells us there is an ongoing programme of decoration, which includes the refurbishment of both bathrooms, though this was also the case at the last key inspection in 2008. Work should have been finished and the bathrooms should have been completed by now. This is a ‘recommendation’ of this report. People say they are very satisfied with their rooms, the cleanliness, warmth and space. Some often spend much of the day there. Relatives are also satisfied with the environment and comment that the home is always clean and free from bad smells. The laundry provides washers, driers and sluicing facilities, so staff can choose from a range of temperatures to ensure people’s clothing and linen is washed correctly. Equipment meets the requirements of the Water Supply (Water Fittings) Regulations 1999. Staff have disposable gloves and aprons to wear for handling soiled linen, which is delivered to the laundry in separate sealed bags. This reduces risk from cross infection. Staff have completed infection control training and the provider has upgraded facilities in all bedrooms by providing soap dispensers and paper towels for staff to use. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well cared for by a skills mix of staff in sufficient numbers, with the recommended qualifications, but not the right training to meet their needs. Staff are poorly recruited according to company policy and procedure and regulations and schedule 2. EVIDENCE: Discussion with people in the home, the provider and staff and viewing of staff files shows there are some shortfalls in the recruiting and training of staff, but that generally staff are qualified to do the job and are sufficient in numbers to be able to meet people’s needs. The provider tells us in the AQAA and verbally that there are ten care staff employed in the home, of which five have NVQ level 2, giving the required 50 of staff with a qualification. Staff also back this up in conversation with them. Staff in interview inform us there are usually three staff on duty each morning and afternoon shift and one waking, one sleeping staff at night. They say this Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 26 is sufficient staff to meet people’s needs, but that they cannot meet needs if a staff member does not turn in. Where possible they cover each other for days off or holidays but cannot always deal with sickness cover. People spoken with did not mention ever having staffing shortages. There is a recruitment and selection policy and procedure in place, but evidence shows that it is not always followed. Four staff files were viewed to check the recruitment practices and it transpires there are shortfalls in meeting the requirements of the standard and schedule 2. Of the files seen one has no job application form so there is no start date available, there is no evidence of references being taken and no induction or supervision details. The CRB is dated March 2004. POVA first checks were not available at that time. Because there is no evidence of a start date it is difficult to determine whether or not this person was recruited according to the requirements of the standard and the regulations. The second file also has no references, but two out of date testimonials dated 2007 and 2008, since this person’s start date is February 2009. She started the job on a POVA first check and six weeks before the CRB check had been received. There is also no evidence of induction or supervision, so this person was not employed according to requirements of the regulations. The third file has only one reference, shows the person’s start date as November 2006 and a CRB check dated December 2006, with no details of a POVA first check at all. Again there is no evidence of induction. This person was not employed according to requirements of the regulations. The fourth file shows the person’s start date as February 2009 with a CRB check dated April 2009, so again this person began working on a POVA first check only, obtained two days before she started. Again there is no evidence of induction or supervision, so again this person was not employed according to requirements of the regulations. Clearly the provider has not followed policy and procedure in recruiting staff safely over the last three years. Discussion with the provider reveals she may not be fully understanding of the requirements of schedule 2, as two from four staff have started in their posts on POVA first checks only and before their CRB check had been received. This should only be the practice in an emergency where staff are desperately needed to start working, and any shift they complete should be supervised by a senior at all times and be recorded. A third started working before her CRB check had been received and without a POVA first check as well. This should not happen at all. Also there are only three from eight instances of references being properly and appropriately obtained. Again discussion reveals the provider believes it is acceptable to take staff on with testimonials. This is not the case. One Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 27 reference must be obtained from the person’s last employer and both references should be followed up by a telephone call. A ‘recommendation’ made at the last random inspection in March 2009 to make sure staff receive training in fire safety, food hygiene and first aid, as well as any other identified course to ensure staff are skilled to do the job, has not entirely been met. Two from four staff files and records seen show fire safety has been completed in the last six months, and that three from four staff have completed first aid. There is no evidence staff have done food hygiene. There is soon to be training for all staff on the Mental Capacity Act 2005, on Deprivation of Liberty (DoL) legislation and on moving and handling, but this is not to be until the provider has completed DoL training planned in November, and four senior staff have completed a ‘train the trainers’ course in moving and handling. The provider has already done Mental Capacity Act 2005 training and the first day of the site visit saw staff going through one of the Mulberry House training sessions on moving and handling. There is more training planned for the next few months, such as infection control and safe handling of medicines, but it is clear that training is still not entirely up to date for everyone. Staff had training and development plans in their files that showed what should be done and what has already been done in the last year. Safeguarding adults was not listed in training plans. Staff in interview confirm what training they have or have not done. They are aware of plans to provide some training sessions in the next few months. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not benefit from a well run home or have their best interests upheld, as there is no registered manager. People are not entirely confident their health, safety and welfare are properly promoted and protected by the home’s systems for maintaining equipment and ensuring risks are reduced. EVIDENCE: Discussion with the provider and staff, viewing of some records, documents, maintenance certificates and systems to monitor the quality of the service Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 29 provided, and to assure the safety of the home and any equipment used, shows there are shortfalls in the management and administration of the home. There has not been a registered manager in the home for three years. There was a period of time when the home did have a registered manager who was finding it difficult to effectively manage the home, and when another person had been brought in to assist in managing, with the view to eventually becoming the registered manager, the then registered manager resigned. In August 2006 the Commission requested in writing that the provider make a declaration of the name of the person who was to be the new manager and supply an application for her to register with them. This has not been forthcoming. When the new manager also left her position in late 2006 the provider took over the managing of the home. This situation has not been formally requested by the provider nor formally accepted by the Commission, and so a registered manager is still required. There is a tentative quality assurance system in place at the moment, but although it consults people in the home with a monthly questionnaire, there is still much room for improvement. The questionnaire asks five simple questions that have a very negative slant to them: any problems with staff, any problems with your room, with the laundry service, with meals, and any other concerns. Five questionnaires returned in Aug 2009 were seen only. The provider explains that she holds meetings in the home with people living there and with staff and that relatives are often consulted when they visit. People spoken with say there are no meetings held and that they are never consulted about anything that happens. The quality assurance system needs to be developed to include a more comprehensive survey of people, their relatives and staff, to include an annual report showing where improvements have been made or are still required and to show what the future plans of the service are. The home does not handle financial affairs of any people living in the home, other than to collect the service charge for their accommodation, care and support. Therefore there are no systems to check for effectiveness. There are systems in place to promote and protect the health, safety and welfare of people and staff in the home and some of these were sampled. There is a clinical waste collection contract in place with Canon for three years from April 2008, so waste management is satisfactory. The hot water storage tank was last checked by ADS Electrical 27/02/09, but a legionella test certificate could not be located, so it is not clear if a bacteria test has been done. There is a periodic electrical installation certificate dated 27/02/09, so the electrical systems in the home are safe. There is a certificate of Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 30 employer’s liability insurance with Allianz which expires 23/05/10, so employer’s liability cover is good. Coastal Stairlifts last maintained the chair lift in November 2008 and so this will soon be due in order to ensure the stair lift is safe for use. Allianz also checked the stair lift 10/06/09. Control of Substances Hazardous to Health (COSHH) information is also held on all cleaning products used, so staff can use such products safely. CMR Plumbing carried out a landlord’s gas safety check on 09/04/09, so the gas installations are safe. Humberside Fire and rescue Service last visited the home on 23/09/09 and made requirements for the fire risk assessment document to be reviewed and updated and for some fire doors to be replaced. There is information to show ADS Electrical also carried out its last bi-annual fire safety system check on 27/02/09. Though there is information to show the risk assessment was reviewed in July 2009 there is no evidence to show that the provider has attended to the fire officer’s requirements to replace the fire safety doors. There is a fire file that contains an index, details of alarm location points and call points, records of fire equipment checks and system tests, and of staff training and fire safety drills held. Evidence shows the fire risk assessment document has been reviewed in July 2009, that weekly alarm tests and monthly lighting tests are carried out, but that there is a need to improve on the holding and recording of fire safety training and fire safety drills. There is only one document evidencing that a group of staff were invited to attend drill instruction on 29/04/09 with their signatures to say they will attend this. However, there is no evidence to show staff actually attended the instruction on that day. There are no other documents to show drill instructions or fire safety drills have been held before this or since then. Such records should show the date, time, who was present, what the drill consisted of and have staff signatures as evidence they were there. All staff should complete a minimum of two fire safety training drills in every twelve month period. There is a clear progressive downturn in the rating of the service, which mainly is due to the managing and administering of the service showing signs of deterioration. Assessments of need, care plans, risk assessments, medication issues, training for staff in all areas, recruitment and selection practices, having no registered manager and ensuring the safety of people all require attention and all impact upon the safeguarding of adults within the home. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X N/A X X 2 Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 32 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 31/12/09 2 OP7 15 3 OP7 15 4 OP7 13 The registered provider must make sure all potential people moving into the home are given a full and detailed assessment of their needs, that information is fully recorded and that they receive in writing confirmation their needs can or cannot be met by the home, so they know their needs will be met once they have moved in. The registered provider must 31/12/09 make sure care plans are person-centred and clearly contain the relevant areas of assessed care needs for individuals and show what action or intervention is required to meet those needs, so people know their needs are met. 28/02/10 The registered provider must make sure care plans are reviewed as required or at least annually and in consultation with people, family and social service officers if appropriate, so people know their needs are being well met. The registered provider must 31/12/09 DS0000019648.V378090.R01.S.doc Version 5.3 Bempton Old Rectory Page 33 5 OP8 12 and 13 6 OP9 13 7 OP12 12 8 OP18 13 9 OP29 18 and 19 make sure all risk assessments are carried out using a risk assessment tool to evidence how risks are deduced and that they are specific and relevant, so people know their needs will be met with as much reduced risk as possible. The registered provider must make sure people’s individual health care needs are fully recorded in their care plan and show evidence of how these needs are being met, so people are confident their changing needs are met. The registered provider must make sure staff administering medications are properly trained to do so and that they are competence checked regularly. All of this must be recorded as evidence, so people are confident they are receiving their medication safely. The registered provider must make sure everyone is consulted about the pastimes and activities they wish to engage in and have their individual interests and expectations met, so they can lead fulfilling lives. The registered provider must make sure regular training is provided for all staff in safeguarding adults, and that they are competence checked for understanding. All of this should be recorded as evidence. It must be done so staff understand the current guidelines about who to report to, and what action to take, should they suspect abuse, or have an allegation made to them and so people are protected from harm. The registered provider must DS0000019648.V378090.R01.S.doc 31/12/09 28/02/10 31/12/09 31/01/10 31/12/09 Page 34 Bempton Old Rectory Version 5.3 10 OP30 13 and 18 11 OP38 13 12 OP38 23 make sure the recruitment and selection procedures are followed and that schedule 2 is adhered to in respect of only employing people after making and receiving a CRB check and obtaining two written references, so people are confident they are cared for and supported by safe staff. The registered provider must 28/02/10 make sure all care staff receive mandatory training or competence assessments in such as fire safety, moving and handling, medication administration, emergency first aid, health and safety etc. and all training must be recorded, so people are confident they are being cared for and supported by competent staff. The registered provider must 28/02/10 make sure there is a three yearly check on the hot water storage tank to test it for the risk of legionella bacteria and a certificate must be obtained as evidence, so people are confident they are protected from the risk of infection. The registered provider must 28/02/10 make sure all staff undertakes regular fire safety training drills, that these are properly recorded and that staff sign to say they have taken part in the drills, as evidence, so people are confident they are protected from the risk of harm from fire. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 35 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The registered provider should make sure copies of the placing local authority community care assessment document, where completed, and copies of the home’s own assessment of needs document are held in case files, so people know their assessed needs informs the care plan staff are to follow to care for and support them. The registered provider should make sure all care documents and records are held together in the case file, so people and staff know when and how their needs are assessed, their care needs are to be met, and their care plans are reviewed. The registered provider should make sure all medication brought into the home is checked and receipted in the appropriate place on the MAR sheet or on some other record, and that any returned medicines are recorded and signed for upon collection, so people are confident they are receiving their medication safely. The registered provider should make sure the complaint record shows details of any investigation, action taken and the outcome for the complainant, so people know their complaints are taken seriously and are resolved effectively. The registered provider should make sure the refurbishment work on the bathrooms is completed in a timely manner, so people know they have suitable bathing facilities to use. The registered provider should make sure they appoint a manager to run the home, and that the appointed manager submits an application to the Commission to become the registered manager, so people know the home is being run and managed by a person fit to do so. The registered provider should make sure the quality assurance system is developed to include surveying people more thoroughly and in a positive way, surveying relatives and staff and to produce a published report of the collective results of surveys to show what the home does well and what the registered provider intends to do where suggestions about improvements are made, so people are confident their views underpin the development of the DS0000019648.V378090.R01.S.doc Version 5.3 Page 36 2 OP7 3 OP9 4 OP16 5 OP19 6 OP31 7 OP33 Bempton Old Rectory service. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 37 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Bempton Old Rectory DS0000019648.V378090.R01.S.doc Version 5.3 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!